1. The document discusses various troubleshooting issues that can occur with cardiac implantable electronic devices (CIEDs) such as pacemakers, including implant-related issues, lead-related issues, and pacemaker malfunctions. 2. Early complications after pacemaker implantation include pneumothorax, hematoma, and lead perforation or dislodgement. Pneumothorax risk factors include procedures using the subclavian vein approach and patient characteristics like female gender, older age, COPD history. 3. Lead-related problems include dislodgement, fracture, and insulation failures. Diagnosis involves chest x-rays and device interrogation. Treatment requires lead repositioning or replacement.

1. 心臟植入性電子儀器(CIED)
護理照護指引-Cathroom
Troubleshooting
中國醫藥大學附設醫院
心臟內科
護理師 洪佩琪

2. Pacemaker Troubleshooting
• Implant related Troubleshooting
• Lead related Troubleshooting
• Pacemaker malfunction

3. Early complications of pacemaker
implantation
– Pneumothorax/Hemothorax/vascular
hemorrhage/AIR Emboli
– SVT, VT/ Cardiac arrest
– Lead dislodgement/Lead perforation

4. Pneumothorax
• Absence of lung markings over the lung
field ipsilateral to the pacemaker pocket
assessed from the fluoroscopy or pre-
discharge x-ray.
• Non-puncture related, might occur at
contralateral side

5. Pneumothorax Sign
• Dyspnea(80~100%)
• Chest pain(75~90%)
• Dry cough(25~35%)
• Hypotension、Tachycardia、SaO2 ↓

6. Pneumothorax
• 0.66% (190/28,860 patients) in Danish Pacemaker
Register
– more often in women [OR 1.9],
– age >80 years [OR 1.4],
– prior history of chronic obstructive pulmonary disease
[OR 3.9]
– implantation of a dual-chamber PM [OR 1.5]
– venous access with subclavian vein puncture [OR 7.8]
– venous access with both subclavian vein puncture and
cephalic vein cut-down [OR 5.7]
– implantation in a non-university center [OR 2.1].

7. Old lady, kyphoscoliosis,
chronic obstructive pulmonary disease

8. venous access with
subclavian vein puncture

9. How to avoid pneumothorax
• The cephalic vein cut-down technique
should be applied whenever possible to
avoid this complication.

10. Pneumothorax nursing care
• Administer oxygen as prescribed.
• Position the client in high fowler’s position.
• Prepare for chest tube placement until the lung
has expanded fully.
• Monitor chest tube drainage system.

11. Air Emboli

12. Air Emboli

13. Air Emboli
• More occurs in
– Un-cooperated patients
– Under respiratory distress
– Old age
– Snoring patients
• Management
– IV resuscitation
– Raise patients’ legs
– Increase FiO2

14. SVT / VT during implantation
• Check Vital sign
• Stable  Medication
RV lead pacing
• Unstable  Cardioversion

15. Lead perforation / cardiac
tamponade
• Rising stimulus threshold, RBBB
morphology
• Intercostal diaphragmatic pacing
• Hypotension

16. Lead perforation / cardiac
tamponade
• Echo
• Cardiocentesis

17. Rare but it happened sometimes

18. Hematoma formation at pulse
generator / due to
anticoagulants

19. Anticoagulation therapy
• Warfarin was temporarily discontinued before device
implantation when possible to achieve an INR value
of < 1.7
• Administration of LMWH was stopped 24 h before the
procedure
• Antiplatelet therapy with ASA or clopidogrel was
allowed to continue
• Treatment with warfarin was resumed after 24 h and
with LMWH after 12–24 h

20. Cardiac arrest
• TPM pacing
• TCP pacing
• RV lead pacing

21. Lead related complications
1. Lead dislodgement
Atrial > Ventricular
2. Lead fracture
3. Loss of integrity of insulation

22. Lead failure
• Development of high pacing thresholds
or sensing problems resulting in the
need to program the device to a
different pacing mode or the need for
reoperation.

24. Lead dislocation

25. Atrial lead dislodge more
frequently

26. Lead Dislodgement

27. Lead Dislodgement
Diagnostic features
– changes in the morphology of
capture beats
– changes in dipole of the
pacing stimulus
– changes in the lead position
identified on a chest
radiograph

28. Lead Dislodgment
Treatment
– surgical intervention to reposition the lead
• an adequate heel on the intracardiac portion of the lead
• look for a 2 to 3mV current of injury pattern
• electrical and mechanical stability of the lead may be
assessed
– Twiddler’s syndrome
• the portion of the lead within the pocket should be
carefully inspected.
• If damage to the conductor coil or insulation is noted, the
lead should not be reused.

29. Order a Chest X-ray
The chest x-ray revealed a dislodged lead

30. Pacemaker system malfunction-
Troubleshooting

31. Pacing Stimuli Present with Failure to
Capture - causes
 Lead dislodgment
• Early: unstable position
• Late: Twiddler’s syndrome
 Lead maturation
• Early: inflammatory response
• Late: progressive fibrosis
 Late high thresholds
• Progressive fibrosis
• Myocardial infarction
• Cardiomyopathy
• Metabolic/drugs
• Damaged lead or tissue
interface
 Insulation failure
 Conductor failure
• Lead fracture
• Loose set-screw
 Battery depletion
 Functional non capture
• Pseudomalfunction

32. Electrical stimuli delivered by
the pacemaker do not initiate
depolarization of the atria or
ventricle
Loss of Capture

33. Loss of Capture
Possible Causes Corrective Measures
•Threshold rise •Increase output (mA)/check thresholds
•Fractured/dislodged lead •Replace/reposition lead
•Battery depletion •Replace battery
•QRS not visible •Adjust ECG
•Tissue is refractory •Assess mode selection
•Faulty cable connections •Check connections
•Switch polarity (epicardial system)

34. Capture
Loss of Ventricular Capture
Atrial/Ventricular Stimulation Thresholds

35. Pacemaker fails to emit stimuli
at the programmed intervals
No Output

36. No Output
Possible Causes Corrective Measures
•Battery depletion •Replace battery
•Pacemaker OFF •Verify pacemaker settings
•Faulty cable connections •Check cable connections
•Fractured/dislodged lead •Replace/reposition lead
•Oversensing •Verify/adjust sensitivity

37. Failure of the pacemaker to sense
intrinsic R-waves or intrinsic
P-waves
Undersensing

38. Undersensing
Possible Causes Corrective Measures
•Decreased QRS voltage •Increase sensitivity
•Fractured/dislodged lead •Replace/reposition Lead
•Battery depletion •Replace battery
•Inappropriate sensitivity setting •Sensing test/increase sensitivity
•Fusion beat

39. Sensing
Atrial Undersensing
Atrial/Ventricular Sensing Thresholds

40. Undersensing . . .Overpacing
• Pacemaker does not “see” the intrinsic
beat, and therefore does not respond
appropriately
Intrinsic beat
not sensed
Scheduled pace
delivered
VVI / 60

41. Inhibition of the pacemaker by events
pacemaker should ignore, e.g. EMI,
T-waves and myopotentials
Oversensing

42. Oversensing
Possible Causes Corrective Measures
•Fractured/dislodged lead •Replace/reposition lead
•Environmental interference •Eliminate interference
•T-wave oversensing •Sensing test/decrease sensitivity
•Faulty cable connections •Check connections

43. Oversensing …Underpacing
• An electrical signal other than the
intended P or R wave is detected
Marker channel
shows intrinsic
activity...
...though no
activity is present
VVI / 60

44. Post implantation test

45. Correct

46. Thanks For Your Attention!